Provider Demographics
NPI:1437187606
Name:SACKS, SHARON (PHD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:SACKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46361-8283
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:1411 S WOODLAND AVE
Practice Address - Street 2:STE B
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7169
Practice Address - Country:US
Practice Address - Phone:219-210-0111
Practice Address - Fax:219-879-2887
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041854A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN202655005 01OtherSAGAMORE HEALTH PLAN
IN000000392276OtherBLUE CROSS & BLUE SHIELD
IN234100Medicare ID - Type UnspecifiedMEDICARE